Provider Demographics
NPI:1972128163
Name:SIMMONS, STACY M (LPC)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:M
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 PFEIFFER AVE
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-5047
Mailing Address - Country:US
Mailing Address - Phone:660-665-4612
Mailing Address - Fax:660-665-4635
Practice Address - Street 1:105 PFEIFFER AVE
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-5047
Practice Address - Country:US
Practice Address - Phone:660-665-4612
Practice Address - Fax:660-665-4635
Is Sole Proprietor?:No
Enumeration Date:2020-06-12
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014041447101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2014041447OtherSTATE OF MISSOURI